RASMUSSEN UNIVERSITY | SCHOOL OF NURSING
NUR 2755 / NUR2755 EXAM 2 (LATEST ):
MULTIDIMENSIONAL CARE IV / MDC 4 - RASMUSSEN
Comprehensive Examination - Aligned with the Rasmussen University NUR 2755 Syllabus, NCLEX-RN Test Plan,
QSEN Competencies, and Multidimensional Care IV Standards
Total Questions: 120 | Content Sections: 8 | Format: Multiple Choice (A-D), one best answer | Cognitive Mix: 20%
Recall / 50% Application / 30% Analysis
Special Inclusions: 20 priority-setting items, 15 pharmacology items, 10 laboratory-interpretation items | Style: 75%
scenario-based / 25% direct knowledge
Directions: Read each client situation carefully and select the ONE best answer (A-D). Each item is followed by its keyed answer
and a rationale that explains why the correct option is best and why the remaining options are less appropriate, with references to the
NUR 2755 Multidimensional Care IV curriculum, NCLEX-RN Client Needs, and QSEN competencies. Content flows continuously
across the eight sections; total review time is approximately 2.5 to 3 hours. Review the rationale for every item - including those
answered correctly - to strengthen clinical judgment before the course examination.
SECTION 1 Complex Cardiovascular & Hematological Disorders Questions 1-20
Q1: A 68-year-old female client with type 2 diabetes arrives at the emergency department reporting unusual
fatigue, mild shortness of breath, and indigestion that began 3 hours ago. Her skin is pale and diaphoretic. Which
explanation best describes why the nurse recognizes this presentation as a possible acute myocardial infarction
(MI)?
A. Diabetic clients develop increased sensitivity to ischemic pain that radiates directly to the epigastrium
B. Women and clients with diabetes often present with vague, atypical symptoms because of autonomic
neuropathy and altered pain perception [CORRECT]
C. Indigestion always indicates gastrointestinal rather than cardiac disease in older adult women
D. Fatigue and dyspnea occur only after the infarction has fully extended through the pericardium
Correct Answer: B
Rationale: Women and clients with diabetes frequently present with atypical MI manifestations - fatigue, dyspnea,
epigastric discomfort, and diaphoresis - rather than classic crushing chest pain, because autonomic neuropathy blunts
ischemic pain perception. Option A is incorrect because pain sensitivity is decreased, not increased. Options C and D are
dangerous misconceptions; GI-like symptoms in this high-risk population require a 12-lead ECG within 10 minutes and
troponin evaluation per acute coronary syndrome guidelines. (NCLEX-RN Client Need: Physiological Adaptation | QSEN:
Safety)
Q2: A 58-year-old client reports substernal chest pressure radiating to the left jaw for the past 45 minutes. The
12-lead ECG shows ST-segment elevation in leads II, III, and aVF. Which action should the nurse take first?
A. Administer a liquid antacid to rule out gastroesophageal reflux
B. Schedule the client for a computed tomography scan of the chest
C. Activate the cardiac catheterization laboratory for emergency percutaneous coronary intervention
[CORRECT]
D. Begin teaching the family about lifestyle modification for secondary prevention
Correct Answer: C
Comprehensive Examination - 120 Questions Page 1
,NUR 2755 EXAM 2 - MULTIDIMENSIONAL CARE IV (MDC 4) RASMUSSEN UNIVERSITY | NCLEX-RN ALIGNED
Rationale: ST elevation in inferior leads confirms a STEMI, and the priority is rapid reperfusion with a door-to-balloon
time of 90 minutes or less per AHA/ACC guidelines, so activating the catheterization lab immediately salvages myocardium.
Antacids and CT scanning delay definitive therapy, and prevention teaching is postponed until recovery. Aspirin, oxygen if
hypoxic, nitroglycerin, and morphine are administered while reperfusion is arranged. (NCLEX-RN Client Need:
Management of Care - Prioritization | QSEN: Teamwork & Collaboration)
Q3: A client admitted with chest pain has a troponin I level of 640 ng/L drawn at admission (reference range
below 40 ng/L), which rises to 1,100 ng/L three hours later. How should the nurse interpret these laboratory
findings?
A. A rising troponin trend confirms ongoing myocardial injury and supports a diagnosis of acute MI
[CORRECT]
B. The elevation indicates skeletal muscle trauma rather than cardiac damage
C. The values are within expected limits for a client presenting with chest pain
D. Falling values would be required before myocardial injury can be confirmed
Correct Answer: A
Rationale: Cardiac troponin I is the most specific biomarker for myocardial injury; a value above the 99th percentile of the
upper reference limit with a rising serial trend is diagnostic of acute MI. Skeletal muscle injury does not significantly elevate
troponin I, so option B is incorrect. The values are markedly abnormal, and it is the rise or fall of serial measurements - not a
falling value alone - that confirms acute injury. (NCLEX-RN Client Need: Reduction of Risk Potential | NUR 2755 MDC 4:
diagnostic reasoning in ACS)
Q4: A client in the ICU after a massive anterior MI becomes hypotensive (BP 82/50 mm Hg) with cool, clammy
skin and scant urine output. Hemodynamic monitoring shows cardiac output 3.2 L/min, cardiac index 1.8
L/min/m2, PAWP 22 mm Hg, and SVR 1,800 dynes (markedly elevated). Which condition do these findings
indicate?
A. Hypovolemic shock from unrecognized third-spacing of fluid
B. Septic shock with vasodilatory collapse
C. Right ventricular infarction with depressed filling pressures
D. Cardiogenic shock with pump failure and compensatory vasoconstriction [CORRECT]
Correct Answer: D
Rationale: Cardiogenic shock produces a low cardiac output and cardiac index (below 2.2 L/min/m2), elevated PAWP
(above 18 mm Hg) from pump failure, and elevated SVR from compensatory vasoconstriction - exactly the profile shown.
Hypovolemia would show a low PAWP, septic shock shows high output with low SVR, and right ventricular infarction
elevates right-sided filling pressures while the wedge remains low or normal. (NCLEX-RN Client Need: Physiological
Adaptation | QSEN: Evidence-Based Practice)
Q5: A client with acute decompensated heart failure develops severe dyspnea, pink frothy sputum, crackles in all
lung fields, and SpO2 of 84%. Which action should the nurse take first?
A. Insert an indwelling urinary catheter to begin strict hourly output monitoring
B. Position the client upright with legs dependent and begin high-flow oxygen [CORRECT]
C. Encourage the client to perform deep-breathing and coughing exercises
D. Obtain a sputum culture and sensitivity before starting antibiotics
Correct Answer: B
Comprehensive Examination - 120 Questions Page 2
,NUR 2755 EXAM 2 - MULTIDIMENSIONAL CARE IV (MDC 4) RASMUSSEN UNIVERSITY | NCLEX-RN ALIGNED
Rationale: High-Fowler position with legs dependent decreases venous return and preload, and high-flow oxygen
immediately corrects profound hypoxemia - these are the lifesaving actions in acute pulmonary edema. Catheter insertion
and sputum cultures occur after stabilization, and deep-breathing exercises are ineffective and exhausting for a client in
florid pulmonary edema. IV diuretics, nitrates, and possible noninvasive ventilation follow. (NCLEX-RN Client Need:
Management of Care - Prioritization | QSEN: Safety)
Q6: A client with heart failure taking digoxin 0.25 mg daily and furosemide reports nausea, anorexia, and blurred
yellow-tinged vision. The apical pulse is 52 beats/min and irregular; serum potassium is 3.1 mEq/L and the
digoxin level is 2.8 ng/mL (therapeutic 0.5-2.0 ng/mL). What is the nurse's best interpretation?
A. The findings reflect the expected therapeutic effects of digoxin therapy
B. The client is experiencing isolated hypokalemia unrelated to digoxin
C. Digoxin toxicity is present, potentiated by diuretic-induced hypokalemia [CORRECT]
D. The client requires an immediate increase in the digoxin dose
Correct Answer: C
Rationale: Nausea, anorexia, visual disturbances with yellow-green halos, bradydysrhythmias, and a level above 2.0 ng/mL
confirm digoxin toxicity; loop-diuretic hypokalemia potentiates toxicity because digoxin competes with potassium at the
sodium-potassium ATPase pump. The nurse should hold the dose, obtain an ECG, monitor electrolytes, and anticipate
digoxin immune fab for severe manifestations. Option A misreads toxicity as therapeutic effect, B ignores the drug
interaction, and D would worsen the toxicity. (NCLEX-RN Client Need: Pharmacological Therapies | QSEN: Safety)
Q7: A client with acute coronary syndrome is started on an intravenous nitroglycerin infusion. Which assessment
is most important for the nurse to monitor during titration of this medication?
A. Blood pressure, titrating to relieve chest pain while maintaining systolic pressure above 90 mm Hg
[CORRECT]
B. Serum potassium level every 2 hours
C. Deep tendon reflexes hourly
D. Pupillary response to light every 15 minutes
Correct Answer: A
Rationale: IV nitroglycerin is titrated to reduce chest pain and preload, but its venodilation can cause profound hypotension,
so continuous blood pressure monitoring with a systolic floor of 90 mm Hg is essential during titration. Potassium
monitoring is irrelevant to nitrate therapy, and reflex or pupillary checks relate to neurologic, not cardiovascular, assessment.
Headache is a common expected adverse effect that may require acetaminophen. (NCLEX-RN Client Need:
Pharmacological Therapies | QSEN: Patient-Centered Care)
Q8: A hospitalized client develops new-onset atrial fibrillation with a ventricular response of 142 beats/min. The
client is hemodynamically stable and denies chest pain. The nurse should anticipate prescriptions for which
interventions?
A. Immediate synchronized cardioversion followed by an amiodarone infusion
B. Unsynchronized defibrillation at 200 joules and an adenosine rapid push
C. Carotid sinus massage and atropine administration
D. Rate control with a beta-blocker or calcium channel blocker plus evaluation for anticoagulation
[CORRECT]
Correct Answer: D
Comprehensive Examination - 120 Questions Page 3
, NUR 2755 EXAM 2 - MULTIDIMENSIONAL CARE IV (MDC 4) RASMUSSEN UNIVERSITY | NCLEX-RN ALIGNED
Rationale: Stable new-onset atrial fibrillation is managed first with rate control (diltiazem or metoprolol) and stroke-risk
stratification using the CHA2DS2-VASc score to guide anticoagulation. Cardioversion is reserved for hemodynamic
instability or elective rhythm control after thrombus is excluded, defibrillation is used only for pulseless rhythms, and carotid
massage with atropine treats bradydysrhythmias. (NCLEX-RN Client Need: Physiological Adaptation | NUR 2755 MDC 4:
dysrhythmia management)
Q9: A client in the telemetry unit develops sustained monomorphic ventricular tachycardia at 160 beats/min with
a blood pressure of 96/60 mm Hg. The client is alert and reports mild palpitations but no chest pain or dyspnea.
Which intervention should the nurse anticipate?
A. Immediate unsynchronized defibrillation
B. Intravenous amiodarone infusion with continuous ECG monitoring [CORRECT]
C. Observation without treatment for 24 hours
D. Insertion of a temporary transvenous pacing wire
Correct Answer: B
Rationale: Stable monomorphic ventricular tachycardia is treated pharmacologically first with an IV antiarrhythmic such as
amiodarone (alternatives include procainamide or lidocaine) under continuous ECG monitoring. Defibrillation is reserved
for pulseless ventricular tachycardia, and synchronized cardioversion is used if the client becomes unstable with hypotension,
chest pain, or altered mentation. Observation delays treatment of a potentially lethal rhythm, and pacing addresses
bradydysrhythmias. (NCLEX-RN Client Need: Physiological Adaptation | QSEN: Safety)
Q10: A client returns to the medical-surgical unit following permanent pacemaker insertion. Which nursing
intervention is most appropriate for the first 24 hours after the procedure?
A. Encourage vigorous range-of-motion exercises of the affected arm
B. Maintain the client on strict NPO status for 24 hours
C. Limit movement of the affected arm and assess the insertion site for bleeding or hematoma
[CORRECT]
D. Remove the pressure dressing each shift to inspect the generator pocket
Correct Answer: C
Rationale: After pacemaker insertion, the arm on the implanted side is restricted from elevation and abduction to prevent
lead dislodgement, and the site is monitored for bleeding, hematoma, and dysrhythmias while pacing capture is verified on
telemetry. Vigorous range of motion risks lead displacement, NPO status is not required, and repeatedly removing the
dressing breaks the sterile protection of the wound. (NCLEX-RN Client Need: Reduction of Risk Potential | NUR 2755
MDC 4: postprocedural cardiac care)
Q11: A client with an implanted cardioverter-defibrillator (ICD) asks what he should do if the device fires and he
feels a jolt while alone at home. Which instruction is correct?
A. Sit or lie down, note how many times the device fires, and notify the provider after the episode
[CORRECT]
B. Stand on one foot so the device can reset its rhythm detection
C. Drive immediately to the nearest emergency department while the device is discharging
D. Place a magnet over the device to stop repeated firing
Correct Answer: A
Comprehensive Examination - 120 Questions Page 4
NUR 2755 / NUR2755 EXAM 2 (LATEST ):
MULTIDIMENSIONAL CARE IV / MDC 4 - RASMUSSEN
Comprehensive Examination - Aligned with the Rasmussen University NUR 2755 Syllabus, NCLEX-RN Test Plan,
QSEN Competencies, and Multidimensional Care IV Standards
Total Questions: 120 | Content Sections: 8 | Format: Multiple Choice (A-D), one best answer | Cognitive Mix: 20%
Recall / 50% Application / 30% Analysis
Special Inclusions: 20 priority-setting items, 15 pharmacology items, 10 laboratory-interpretation items | Style: 75%
scenario-based / 25% direct knowledge
Directions: Read each client situation carefully and select the ONE best answer (A-D). Each item is followed by its keyed answer
and a rationale that explains why the correct option is best and why the remaining options are less appropriate, with references to the
NUR 2755 Multidimensional Care IV curriculum, NCLEX-RN Client Needs, and QSEN competencies. Content flows continuously
across the eight sections; total review time is approximately 2.5 to 3 hours. Review the rationale for every item - including those
answered correctly - to strengthen clinical judgment before the course examination.
SECTION 1 Complex Cardiovascular & Hematological Disorders Questions 1-20
Q1: A 68-year-old female client with type 2 diabetes arrives at the emergency department reporting unusual
fatigue, mild shortness of breath, and indigestion that began 3 hours ago. Her skin is pale and diaphoretic. Which
explanation best describes why the nurse recognizes this presentation as a possible acute myocardial infarction
(MI)?
A. Diabetic clients develop increased sensitivity to ischemic pain that radiates directly to the epigastrium
B. Women and clients with diabetes often present with vague, atypical symptoms because of autonomic
neuropathy and altered pain perception [CORRECT]
C. Indigestion always indicates gastrointestinal rather than cardiac disease in older adult women
D. Fatigue and dyspnea occur only after the infarction has fully extended through the pericardium
Correct Answer: B
Rationale: Women and clients with diabetes frequently present with atypical MI manifestations - fatigue, dyspnea,
epigastric discomfort, and diaphoresis - rather than classic crushing chest pain, because autonomic neuropathy blunts
ischemic pain perception. Option A is incorrect because pain sensitivity is decreased, not increased. Options C and D are
dangerous misconceptions; GI-like symptoms in this high-risk population require a 12-lead ECG within 10 minutes and
troponin evaluation per acute coronary syndrome guidelines. (NCLEX-RN Client Need: Physiological Adaptation | QSEN:
Safety)
Q2: A 58-year-old client reports substernal chest pressure radiating to the left jaw for the past 45 minutes. The
12-lead ECG shows ST-segment elevation in leads II, III, and aVF. Which action should the nurse take first?
A. Administer a liquid antacid to rule out gastroesophageal reflux
B. Schedule the client for a computed tomography scan of the chest
C. Activate the cardiac catheterization laboratory for emergency percutaneous coronary intervention
[CORRECT]
D. Begin teaching the family about lifestyle modification for secondary prevention
Correct Answer: C
Comprehensive Examination - 120 Questions Page 1
,NUR 2755 EXAM 2 - MULTIDIMENSIONAL CARE IV (MDC 4) RASMUSSEN UNIVERSITY | NCLEX-RN ALIGNED
Rationale: ST elevation in inferior leads confirms a STEMI, and the priority is rapid reperfusion with a door-to-balloon
time of 90 minutes or less per AHA/ACC guidelines, so activating the catheterization lab immediately salvages myocardium.
Antacids and CT scanning delay definitive therapy, and prevention teaching is postponed until recovery. Aspirin, oxygen if
hypoxic, nitroglycerin, and morphine are administered while reperfusion is arranged. (NCLEX-RN Client Need:
Management of Care - Prioritization | QSEN: Teamwork & Collaboration)
Q3: A client admitted with chest pain has a troponin I level of 640 ng/L drawn at admission (reference range
below 40 ng/L), which rises to 1,100 ng/L three hours later. How should the nurse interpret these laboratory
findings?
A. A rising troponin trend confirms ongoing myocardial injury and supports a diagnosis of acute MI
[CORRECT]
B. The elevation indicates skeletal muscle trauma rather than cardiac damage
C. The values are within expected limits for a client presenting with chest pain
D. Falling values would be required before myocardial injury can be confirmed
Correct Answer: A
Rationale: Cardiac troponin I is the most specific biomarker for myocardial injury; a value above the 99th percentile of the
upper reference limit with a rising serial trend is diagnostic of acute MI. Skeletal muscle injury does not significantly elevate
troponin I, so option B is incorrect. The values are markedly abnormal, and it is the rise or fall of serial measurements - not a
falling value alone - that confirms acute injury. (NCLEX-RN Client Need: Reduction of Risk Potential | NUR 2755 MDC 4:
diagnostic reasoning in ACS)
Q4: A client in the ICU after a massive anterior MI becomes hypotensive (BP 82/50 mm Hg) with cool, clammy
skin and scant urine output. Hemodynamic monitoring shows cardiac output 3.2 L/min, cardiac index 1.8
L/min/m2, PAWP 22 mm Hg, and SVR 1,800 dynes (markedly elevated). Which condition do these findings
indicate?
A. Hypovolemic shock from unrecognized third-spacing of fluid
B. Septic shock with vasodilatory collapse
C. Right ventricular infarction with depressed filling pressures
D. Cardiogenic shock with pump failure and compensatory vasoconstriction [CORRECT]
Correct Answer: D
Rationale: Cardiogenic shock produces a low cardiac output and cardiac index (below 2.2 L/min/m2), elevated PAWP
(above 18 mm Hg) from pump failure, and elevated SVR from compensatory vasoconstriction - exactly the profile shown.
Hypovolemia would show a low PAWP, septic shock shows high output with low SVR, and right ventricular infarction
elevates right-sided filling pressures while the wedge remains low or normal. (NCLEX-RN Client Need: Physiological
Adaptation | QSEN: Evidence-Based Practice)
Q5: A client with acute decompensated heart failure develops severe dyspnea, pink frothy sputum, crackles in all
lung fields, and SpO2 of 84%. Which action should the nurse take first?
A. Insert an indwelling urinary catheter to begin strict hourly output monitoring
B. Position the client upright with legs dependent and begin high-flow oxygen [CORRECT]
C. Encourage the client to perform deep-breathing and coughing exercises
D. Obtain a sputum culture and sensitivity before starting antibiotics
Correct Answer: B
Comprehensive Examination - 120 Questions Page 2
,NUR 2755 EXAM 2 - MULTIDIMENSIONAL CARE IV (MDC 4) RASMUSSEN UNIVERSITY | NCLEX-RN ALIGNED
Rationale: High-Fowler position with legs dependent decreases venous return and preload, and high-flow oxygen
immediately corrects profound hypoxemia - these are the lifesaving actions in acute pulmonary edema. Catheter insertion
and sputum cultures occur after stabilization, and deep-breathing exercises are ineffective and exhausting for a client in
florid pulmonary edema. IV diuretics, nitrates, and possible noninvasive ventilation follow. (NCLEX-RN Client Need:
Management of Care - Prioritization | QSEN: Safety)
Q6: A client with heart failure taking digoxin 0.25 mg daily and furosemide reports nausea, anorexia, and blurred
yellow-tinged vision. The apical pulse is 52 beats/min and irregular; serum potassium is 3.1 mEq/L and the
digoxin level is 2.8 ng/mL (therapeutic 0.5-2.0 ng/mL). What is the nurse's best interpretation?
A. The findings reflect the expected therapeutic effects of digoxin therapy
B. The client is experiencing isolated hypokalemia unrelated to digoxin
C. Digoxin toxicity is present, potentiated by diuretic-induced hypokalemia [CORRECT]
D. The client requires an immediate increase in the digoxin dose
Correct Answer: C
Rationale: Nausea, anorexia, visual disturbances with yellow-green halos, bradydysrhythmias, and a level above 2.0 ng/mL
confirm digoxin toxicity; loop-diuretic hypokalemia potentiates toxicity because digoxin competes with potassium at the
sodium-potassium ATPase pump. The nurse should hold the dose, obtain an ECG, monitor electrolytes, and anticipate
digoxin immune fab for severe manifestations. Option A misreads toxicity as therapeutic effect, B ignores the drug
interaction, and D would worsen the toxicity. (NCLEX-RN Client Need: Pharmacological Therapies | QSEN: Safety)
Q7: A client with acute coronary syndrome is started on an intravenous nitroglycerin infusion. Which assessment
is most important for the nurse to monitor during titration of this medication?
A. Blood pressure, titrating to relieve chest pain while maintaining systolic pressure above 90 mm Hg
[CORRECT]
B. Serum potassium level every 2 hours
C. Deep tendon reflexes hourly
D. Pupillary response to light every 15 minutes
Correct Answer: A
Rationale: IV nitroglycerin is titrated to reduce chest pain and preload, but its venodilation can cause profound hypotension,
so continuous blood pressure monitoring with a systolic floor of 90 mm Hg is essential during titration. Potassium
monitoring is irrelevant to nitrate therapy, and reflex or pupillary checks relate to neurologic, not cardiovascular, assessment.
Headache is a common expected adverse effect that may require acetaminophen. (NCLEX-RN Client Need:
Pharmacological Therapies | QSEN: Patient-Centered Care)
Q8: A hospitalized client develops new-onset atrial fibrillation with a ventricular response of 142 beats/min. The
client is hemodynamically stable and denies chest pain. The nurse should anticipate prescriptions for which
interventions?
A. Immediate synchronized cardioversion followed by an amiodarone infusion
B. Unsynchronized defibrillation at 200 joules and an adenosine rapid push
C. Carotid sinus massage and atropine administration
D. Rate control with a beta-blocker or calcium channel blocker plus evaluation for anticoagulation
[CORRECT]
Correct Answer: D
Comprehensive Examination - 120 Questions Page 3
, NUR 2755 EXAM 2 - MULTIDIMENSIONAL CARE IV (MDC 4) RASMUSSEN UNIVERSITY | NCLEX-RN ALIGNED
Rationale: Stable new-onset atrial fibrillation is managed first with rate control (diltiazem or metoprolol) and stroke-risk
stratification using the CHA2DS2-VASc score to guide anticoagulation. Cardioversion is reserved for hemodynamic
instability or elective rhythm control after thrombus is excluded, defibrillation is used only for pulseless rhythms, and carotid
massage with atropine treats bradydysrhythmias. (NCLEX-RN Client Need: Physiological Adaptation | NUR 2755 MDC 4:
dysrhythmia management)
Q9: A client in the telemetry unit develops sustained monomorphic ventricular tachycardia at 160 beats/min with
a blood pressure of 96/60 mm Hg. The client is alert and reports mild palpitations but no chest pain or dyspnea.
Which intervention should the nurse anticipate?
A. Immediate unsynchronized defibrillation
B. Intravenous amiodarone infusion with continuous ECG monitoring [CORRECT]
C. Observation without treatment for 24 hours
D. Insertion of a temporary transvenous pacing wire
Correct Answer: B
Rationale: Stable monomorphic ventricular tachycardia is treated pharmacologically first with an IV antiarrhythmic such as
amiodarone (alternatives include procainamide or lidocaine) under continuous ECG monitoring. Defibrillation is reserved
for pulseless ventricular tachycardia, and synchronized cardioversion is used if the client becomes unstable with hypotension,
chest pain, or altered mentation. Observation delays treatment of a potentially lethal rhythm, and pacing addresses
bradydysrhythmias. (NCLEX-RN Client Need: Physiological Adaptation | QSEN: Safety)
Q10: A client returns to the medical-surgical unit following permanent pacemaker insertion. Which nursing
intervention is most appropriate for the first 24 hours after the procedure?
A. Encourage vigorous range-of-motion exercises of the affected arm
B. Maintain the client on strict NPO status for 24 hours
C. Limit movement of the affected arm and assess the insertion site for bleeding or hematoma
[CORRECT]
D. Remove the pressure dressing each shift to inspect the generator pocket
Correct Answer: C
Rationale: After pacemaker insertion, the arm on the implanted side is restricted from elevation and abduction to prevent
lead dislodgement, and the site is monitored for bleeding, hematoma, and dysrhythmias while pacing capture is verified on
telemetry. Vigorous range of motion risks lead displacement, NPO status is not required, and repeatedly removing the
dressing breaks the sterile protection of the wound. (NCLEX-RN Client Need: Reduction of Risk Potential | NUR 2755
MDC 4: postprocedural cardiac care)
Q11: A client with an implanted cardioverter-defibrillator (ICD) asks what he should do if the device fires and he
feels a jolt while alone at home. Which instruction is correct?
A. Sit or lie down, note how many times the device fires, and notify the provider after the episode
[CORRECT]
B. Stand on one foot so the device can reset its rhythm detection
C. Drive immediately to the nearest emergency department while the device is discharging
D. Place a magnet over the device to stop repeated firing
Correct Answer: A
Comprehensive Examination - 120 Questions Page 4
